Job Title: / Quality Improvement Facilitator
Band: / 7
Department: / Medical
Hours / 37.5 hours per week
Location: / Trustwide. Based at Maudsley Hospital – Denmark Hill
Reports to: / Quality Improvement Programme Manager

Job Purpose:

The South London and Maudsley NHS Foundation Trust is committed to ensuring that all inpatient and community care provision across the Trust is of the best quality and meets the highest standards. The Trust has committed to embrace quality as the overarching principle for the organisation and set its longer-term mission to provide the highest quality mental health and community care in England. The primary purpose of the Quality Improvement (QI) Programme will be to oversee the transformation of the culture of the Trust to one of continuous improvement which is delivered through participation of all staff in the design, implementation, monitoring and evaluation of a large number of Plan, Do, Study, Act (PDSA) / small-scale projects via a multi-year organisation-wide programme. The Programme is unique one for the organisation in terms of breadth, depth and timescale.

The quality improvement lead provides leadership to clinical teams within the quality improvement directorate to ensure delivery of effective and efficient programs to drive continuous improvements in healthcare service delivery. This post is one of five Quality Improvement leads who together are responsible for a broad portfolio of improvement activities and interactions in the directorate of Quality Improvement.

Our Commitments:

Key Job Dimensions

Central QI Team Structure

In the initial phase of the programme, the central QI team will consist of the following structure:

Key Responsibilities:

Organisation:

  • Plan and communicate the objectives of improvement project to the Clinical Team and to formulate reports on progress.
  • Identify risks in the project plan and put measures in place to remove or minimise these in a timely manner. Make adjustment to the project plans so that the work plan remains on target.
  • To represent the Directorate/Trust at local, regional and national level, to disseminate developments/results from the Improvement programme.
  • To work closely with other departments across the Trust for example Estates and Facilities, Pharmacy and Catering to improve systems and processes on the wards and community teams.

Facilitation and Training:

  • To design and lead service redesign days and events for staff from different professional and staff groups to ensure full understanding and engagement in all service redesign processes as indicated by the Programme.
  • Plan, deliver and facilitate module implementation training sessions to fit with the team needs, taking into account any anticipated barriers to success.
  • To coach, train and support clinical and non-clinical staff in using improvement principles and to ensure that they are embedded in practice.
  • Facilitate teams to work together to improve their own performance for example, helping them to set a rationale, vision and plan to achieve performance improvements.
  • Contribute to the service improvement knowledge and skills within the Trust.
  • Facilitate networking and sharing of best practice across the Trust.
  • Have the ability to teach quality improvement concepts, tools and techniques.

Change Management Working:

  • In partnership with the Ward Managers, Team Leaders and General Managers, the post holder will be responsible for ensuring that clinical teams are competent in the implementation of improvement techniques.
  • Work with the team to and local stakeholders to design new service models and pathways.
  • To employ a range of change management, facilitation and negotiation skills that enable full participation of team members.
  • To influence and motivate teams to adapt new ways of working to improve service delivery and performance.
  • To influence the service users outcomes/experience of care through implementation of service re-designs.
  • To create a working climate that encourages flexible team working amongst staff whilst allowing them the opportunity to show initiative.
  • Encourage staff to participate in a shared governance approach to decision making. To initiate and implement change effectively in response to clinical or organisational demands.
  • To monitor and review the impact of implementation of the Programme in the designated clinical areas.
  • To challenge existing practices, ensuring progressive solutions, which take into account models of best practice and best use of resources.

Communication and Relationships:

  • To develop and implement a locally agreed communication strategy with the clinical teams and other departments.
  • To be responsible for ensuring effective communication between the ward/community team and Programme team takes place.
  • To facilitate communication, which results in clear responsibilities being identified within the multi-professional team.
  • To gain commitment and appropriate participation from all stakeholders by developing and maintaining effective working relationships.
  • To receive, interpret and communicate complex, sensitive and contentious information where there are barriers to acceptance and hostility to change, for example when presenting an analysis of clinical performance to clinical and/or management teams.
  • Develop both formal and informal contacts and networks to share learning and knowledge within the Trust, and with local and national social and healthcare community.
  • To lead on producing reports.
  • To employ a range of communication techniques to impart complex information to a range of audiences (large and small, external and internal) and to build support for change initiatives and overcome resistance.
  • To be responsible for the delivery of regular reports on the Programme progress to the Programme lead and other senior stakeholders.
  • Identify and develop thought leaders who will be able to assist in the advancing of the quality agenda in the Trust.
  • To work closely with service users and carers on the improvement projects.

Programme Management of Improvement Work:

  • Including supporting services to set up programme governance structures, produce programme plans, and set clear goals.
  • Produce risk and issue logs and develop communication strategies.
  • Advise ward and community team leaders on programme management methodologies. Participate as an active member of programme groups in a service improvement capacity, performing delegated tasks on time and to a high standard.
  • Support the Programme Leader to develop, update and maintain the Trust wide performance improvement plan for review. On a monthly basis provide status summaries and update risk and issues logs to the Programme Manager.
  • To assess and evaluate programme progress against agreed timescales and objectives and provide solutions to address any deviations.
  • To identify where Improvement projects will impact on budgets and ensure all work is financially sound and will not impact negatively.
  • To use excellent presentation skills to present a range of new and unfamiliar concepts to Trust staff at all levels and externally to the Trust to professionals in the wider health community and be able to manage varying levels of understanding.
  • To disseminate findings to wider healthcare community, for example, through recognised journals or conferences as appropriate.
  • To participate in audit and data collection and have the skills and ability to regularly design, create and maintain appropriate information systems (databases and spreadsheets) for Violence Reduction Programme data.
  • To work with the Quality Improvement Programme Manager to appraise the quality of information and make judgements regarding action to be taken in light of the new information which may be limited.
  • To collate, provide and analyse qualitative and quantitative information relating to patient care/outcomes when required.
  • To be responsible for the maintenance of accurate records and databases.
  • Evaluate the impact of change occurring during the project and manage effectively.

Professionalism:

  • To work independently without direct supervision, but with support and guidance from Programme Manager and Deputy Medical Director.
  • To acknowledge own personal and professional limitations and seek advice or support when required.
  • Provide formal and informal support and guidance to other clinical and non-clinical staff.
  • Undertake continued professional development and maintain a written record. To work in a way that ensures patient confidentiality is assured at all times according to Trust and Departmental policies and procedures.
  • To undertake any other duties relevant to this position deemed necessary in line with changing practice and service needs.
  • To participate regularly, in clinical and managerial supervision.
  • To act in accordance with the Professional Code of Conduct, and to ensure effective registration if required.
  • To identify training and development needs in consultation with Programme Manager.

Analysis and Data Management:

  • To take ownership of data within their project workstreams.
  • Develop systems for data collection and measurement.
  • Set up project measures.
  • Develop ownership of data at team level.
  • Prepare systems so that data can be maintained within the Trust at project end.
  • Help develop quality improvement measurement across the Trust.
  • Use a variety of data sources. Undertake ad hoc requests for data gathering and analysis from all levels within the Trust.

Research, Development and Audit:

  • Work with governance teams and help to provide expertise to the organisation in quality audit processes.
  • Work alongside colleagues at King’s College London in the development and delivery of research related to quality improvement and implementation science.

Governance:

  • To actively participate in governance activities to ensure that the highest standards of care and business conduct are achieved.
  • To attend and provide feedback to Programme Board and weekly progress meetings on the wards and Community teams.
  • To comply with all Trust policies, procedures and practices and to be responsible for keeping up to date with any changes to these.
  • To facilitate and support the design and use of audits to capture the progress services are making on service improvement and collate the evidence to demonstrate the effectiveness of improvement activities.
  • To ensure risks are identified and monitored and solutions sought to support the delivery of the outcome and benefits.

Personal Specification:

Each requirement will either be identified through the candidate’s application form (A) or interview (I). Candidates should ensure they read and understand the requirements below and ensure they have the relevant experience/knowledge before applying. South London and Maudsley NHS Foundation Trust are committed to developing staff and will offer relevant training and development opportunities where desirable requirements are missing.

Requirements / Essential / A/I / Desirable / A/I
Qualifications /
  • First Degree – 2:2 or above
  • Postgraduate level qualification (or equivalent) in Leadership/Management
/ A
A /
  • Masters Degree
  • Post-graduate experience in quality improvement, change management, leadership, service redesign, or patient safety
/ A
A
Previous Experience /
  • Extensive experience in relevant professional environment
  • Previous project management experience
  • Experience of service redesign or quality initiative
  • Experience of using patient process redesign and/or other techniques to improve service
  • Experience of facilitating group discussions, training and team working
  • Experience of working with Multidisciplinary staff and securing their engagement
  • Experience of working with service users and of supporting them to work alongside clinicians
  • Experience of working in complex and multi-professional organisations
  • Audit or research within the clinical area
/ A
A
A/I
A/I
A/I
A/I
A/I
A/I
A/I
Skills, abilities and attributes /
  • Communication and Relationship Skills
  • Able to present and receive complex information within the multi professional team
  • Demonstrate evidence of providing formal teaching sessions
  • Demonstrate negotiation and influencing skills
  • Assertiveness skills and the ability to deal with conflict
  • Team player who can initiate, delegate and complete projects
  • Demonstrate self-awareness and understanding of personal accountability
/ A/I
A/I
A/I
A/I
A/I
A/I
A/I /
  • Knowledge of and Experience of Improvement Methods e.g. Lean, Six Sigma, Collaborative models, Model for Improvement
  • Knowledge of Statistical Process control
/ A/I
A/I
Knowledge /
  • Knowledge of change management methodology and the change process.
  • Demonstrable knowledge of process mapping and redesign techniques, demand and capacity analysis.
  • Knowledge of Project and Programme Management methodology.
  • An awareness of national health policy.
  • Analytical and Judgement Skills
  • Ability to generate and present reports and documents.
  • Demonstrate insight in the use of data to influence patient care and services.
  • Ability to receive, interpret and communicate complex data, which require analysis, interpretation and comparison of a range of options.
  • Ability to assess and evaluate project progress against agreed timescales and objectives and provide solutions to address any deviations.
  • Ability to formulate short and long term objectives
  • Ability to apply project management methodologies to plan and implement service improvements.
  • Ability to work Trustwide and to cope with the complexity that results from work with a wide range of different teams, systems and structures.
  • Facilitation skills: ability to facilitate the direct involvement of service users or to incorporate their views into processes.
  • Ability to stimulate a creative thinking environment for teams, to problem solve and to support others to develop this skill.
/ A/I
A/I
A/I
A/I
A/I
A/I
A/I
A/I
A/I
A/I
A/I
A/I
A/I
Other requirements relevant to the post /
  • Self-motivated, able to act on own initiative and work independently
  • Flexible and adaptable
  • Enthusiastic and well-motivated.
/ I
I
A/I /
  • Evidence of writing Journal articles, Grant applications, Award applications
/ A/I

About South London and Maudsley:

South London and Maudsley NHS Foundation Trust (SLaM) provide the widest range of NHS mental health services in the UK as well as substance misuse services for people who are addicted to drugs and alcohol. We work closely with the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London and are part of King's Health Partners Academic Health Sciences Centre. There are very few organisations in the world that have such wide-ranging capabilities working with mental illness. Our scope is unique because it is built on three major foundations: care and treatment, science and research, and training.

SLaM employ around 5000 staff and serve a local population of 1.1 million people. We have more than 230 services including inpatient wards, outpatient and community services. Currently, provide inpatient care for approximately 5,300 people each year and treat more than 45,000 patients in the community in Croydon, Lambeth, Lewisham and Southwark; as well as substance misuse services for residents of Bexley, Bromley and Greenwich.

By coming to work at SLaM, you will gain experience of being part of an organisation with a rich history and international reputation in mental health care. You will have access to professional development and learning opportunities, and have the chance to work alongside people who are world leaders in their field. SLaM delivered more than 14,000 training experiences in 2014; providing an extensive range of learning opportunities for staff at all levels. In addition, our working relationship with King's Health Partners allows those working at the Trust to get involved in academic research.

Trust Policy and Procedures:

Confidentiality:
Confidentiality/data protection regarding all personal information and Trust activity must be maintained at all times (both in and out of working hours) in accordance with professional codes of conduct and relevant legislation such as the Data Protection Act. The post holder should ensure that they are familiar with and adhere to all Trust Information governance policies and procedures. Any breach of confidentiality will be taken seriously and appropriate disciplinary action may be taken.

Equal Opportunities:
Promote the concepts of equality of opportunity and managing diversity Trust wide.

Health and Safety:
Employees must be aware of the responsibilities placed upon them under the Health and Safety at Work Act 1974, paying due regard to health and safety in the workplace and management of risk to maintain a safe working environment for service users, visitors and employees.

Infection Prevention and Control:
Employees must be aware of their responsibilities to protect service users, visitors and employees against the risks of acquiring health care associated infections, in accordance with Trust policy.

Professional standards and performance review:
Maintain consistently high professional standards and act in accordance with the relevant professional code of conduct. Employees are expected to participate in the performance review process.

Service/Department standards:
Support the development of performance standards within the Service/Department to ensure the service is responsive to and meeting the needs of its customers.

Finance:
All Trust staff will comply with the financial processes and procedures.

Safeguarding Children & Vulnerable Adults:
Employees must be aware of the responsibilities placed on them under the Children Act 1989, 2004 and the trusts safe guarding vulnerable adults policy.

Code of Conduct:
The post holder is required to adhere to the standards of conduct expected of all NHS managers set out in the Code of Conduct for NHS managers.

This job description will be subject to regular review and adjustment.

SUMMARY:
This job description is an outline of the key tasks and responsibilities of the post and the post holder may be required to undertake additional duties appropriate to the pay band. The post may change over time to reflect the developing needs of the Trust and its services, as well as the personal development of the post holder.